Original Article

Incisional Hernia Repair by Preperitoneal (Sublay) Mesh

Implantation
Fakhar Hameed , Bashir Ahmed, Asrar Ahmed, Riaz Hussain Dab, Dilawaiz
ABSTRACT
Incisional Hernia is a common surgical condition
with a reported incidence of 2-11% following all
laparatomies. Results of tissue repair have been
disappointing. The optimal approach for abdominal
incisional hernias is still under discussion.
Aims: To evaluate the technique of preperitoneal
(sublay) mesh repair of incisional hernias.
Material and Methods: This retrospective study of
consecutive 50 cases was done from January .2004
to January 2006 using a computerized database.
Preperitoneal (sublay) mesh implantation was done
in all the 50 cases. Follow up of 12-24 months was
carried in the OPD and on telephone with regards to
postoperative complications, hospital stay and
recurrences if any.
Results: In our study of fifty patients, eighty
percent of females (n= 40) outnumbered twenty
percent males (n=10). The female to male ratio was
4: 1 and the highest incidence was in the 5th decade
of life. The main presenting feature was swelling

of the abdomen in all the fifty patients (100%) in

the vicinity of the previous operative scar. In sixty
percent of patients (n=30), the most common
incision leading to incisional hernia was the midline
incision of abdomen followed by Pfannensteils
incision in fourteen percent ( n=7) and paramedian
incision in twelve ( n=6). Major wound infection
occurred in two patients (4%) only but without the
removal of mesh. Forty patients (80%) attended for
follow up ranging from 12 months to 24 months.
Twenty seven patients (67.5%) attended OPD for
follow up and thirteen patients (32.5%) replied the
questions on phone. No recurrence was noted in
follow up group.
Conclusion: Based on this study, we conclude that
preperitoneal (sublay) mesh repair is the ideal
technique for incisional hernia. Though still there
are few publications regarding this technique of
repair.
Keywords:
Incisional hernia, preperitoneal
(sublay), mesh repair.

INTRODUCTION
Incisional hernia is defined as a defect occurring
through the operative scar. It is the only hernia
considered to be truly iatrogenic. It occurs due to the
failure of the lines of closure of abdominal wall
following laparotomy [1,2]. An incisional hernia
occurs when all the layers except the skin fail to heal.
It is one of the most common conditions requiring
major surgery despite advances in surgical techniques
and suture material. The incidence of incisional hernia
in literature is 2- 11% following all laparotomies [3]
and it is a source of morbidity and requires high health
care costs. As a result of high recurrence rate in the
repair of incisional hernia, various types of repairs
have been used both anatomical and prosthetic. But the
results have been disappointing with a high incidence
of recurrence of about 30-50% after anatomical repair

[4] and 1.5-10% following prosthetic mesh repairs [5].

The introduction of prosthetics has revolutionized
hernia surgery with the concept of tension free repair.
Although a wide variety of surgical procedures have
been adopted for the repair of incisional hernia, but the
implantation of prosthetic mesh remains the most
efficient method of dealing with incisional hernia [6].
The prosthetic mesh can be placed between the
subcutaneous tissues of the abdominal wall and the
anterior rectus sheath (onlay mesh repair) as well as in
the preperitoneal plane created between the rectus
muscle and posterior rectus sheath (sublay mesh
repair). The later technique has several advantages one
of being not transmitting the infection from
subcutaneous tissues down to the mesh as it lies quite
deep in the preperitoneal plane [7].

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Moreover the mesh implanted in the preperitoneal

space unites and consolidates the anterior abdominal
wall. The mesh also adheres to the posterior rectus
sheath and renders it inextensible allowing no further
herniation.
The preperitoneal (sublay) mesh hernia repair was first
described by Renestopa [8] Jean Rives [9] and George
Wantz [10]. This technique is considered by many
surgeons to be the gold standard for the open repair of
abdominal incisional hernia [11,12,13,14].
The
present study was undertaken to evaluate the technique
of preperitoneal (sublay) mesh repair of incisional
hernias with regards to post operative complications,
hospital stay and recurrences, if any.
MATERIAL AND METHODS
This retrospective study of incisional hernia repair by
preperitoneal mesh implantation was carried out on 50
cases
collected
consecutively
at
Divisional
Headquarters Hospital Punjab Medical College
Faisalabad over a period of two years from
January.2004 to January.2006. The age of the patients
included in the study varies from 15 years to 60 years.
Regarding the sex wise distribution, eighty percent
patients were females (n= 40) and twenty percent were
male (n=10). All patients were admitted through
outpatient department (OPD). The epidemiological
data i.e. the name, age, sex, medical record number,
postal address and phone number was noted at the time
of admission. The clinical features and their duration,
time of initial operation and the interval between the
first surgery and appearance of incisional hernia were
asked from patients and recorded in the data. The
known suspected risk factors like obesity, diabetes and
history of wound infection, type of incision made were
noted and recorded in the data. All the details were
entered in the database and results were statistically
analyzed by Statistical Package for Social Sciences
(SPSS). The follow up of the patients every three
monthly for two years was carried out in the OPD to
see the complications like wound infection and
recurrences if any.

Exclusion Criteria:
1. All the patients with chronic obstructive
pulmonary Disease (COPD) like asthma.
2. Patients with abdominal malignancy & cirrhosis
with endstage liver disease.
3. Patients with previous loss of the abdominal wall
& large scarred area of the abdominal skin.
4. Patients with age less than 15 years & more than
65 years.
5. Patients with size of hernia larger than 15 cm in
its largest dimension.
Operative Technique:
The principles of the
preperitoneal or sublay mesh repair include. Mesh
placement deep to the recti muscles, peripheral suture
fixation, mesh extension well beyond the hernia defect
and closure of the fascia over the mesh.
Fibrous tissue in growth in the porus mesh
consolidates the abdominal wall and widely disperses
intra abdominal pressure to prevent recurrence.
Our technique involves the placement of prosthetic
mesh (Polypropylene) in a preperitoneal plane. After
incising the subcutaneous tissue, the sac is dissected
and delineated. The defect is opened. A plane is
created between the posterior rectus
sheath and the rectus muscle for the placement of the
mesh. The posterior rectus sheath alongwith the
peritoneum is closed with 2/0 prolene suture. A
prolene mesh tailored to the size is placed in the plane
created behind the recti. The mesh is secured with few
interrupted 2/0 polypropylene sutures. A suction drain
is placed over the mesh. The anterior rectus sheath is
closed with continuous 1/0 polypropylene sutures.
Another drain is placed in the subcutaneous plane and
the skin closed. Drains were removed when drainage
was less than 20ml in 24 hours. All the patients were
given 1gm 3rd generation cephalosporin antibiotic
preoperatively at the time of induction and continued
till the 5th postoperative day twice daily. The hospital
stay of the patients was also recorded down.

Inclusion Criteria:
1. All the patients with incisional hernia between
15 and 60 years without sex discrimination.
2. Incisional hernias located in the upper and
lower midline incisions of the abdomen.
3. Incisional hernias resulting from the
pfannensteils incision
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RESULTS
Age & Sex Wise Distribution: Fifty patients
underwent preperitoneal (sublay) mesh repair of
incisional hernia during two year study from January
2004 to January 2006. The youngest patient was 29
year old and the oldest was 60 years old. Eighty
percent patients (n=40) were females which
outnumbered the twenty percent (n=10) male patients.
The female to male ratio was 4: 1 showing that
incidence of incisional hernia is higher in females. The
highest incidence (50%) of incisional hernia amongst
them was in the 5th decade of life. In all the fifty
patients, hernia appeared during the
first year after surgery.

fourteen percent (n=2) patients but the mesh was not

removed in any of the cases.

Table-1
Age & Sex wise Distribution of Patients with
Incisional Hernia
Age in
Male
Female Total Percentage
year
15 30
2
8
10
20
31- 50
3
12
15
30
51- 60
5
20
25
50

Drains: Drains were used in all the patients. The

period of drainage ranged from 3-8 days with the
average period being 4- 6 days.
Follow up: Forty patients (80%) attended our follow
up which ranged from 12 months to 24 months.
Twenty seven (67.5%) patients attended the OPD
personally for follow up. Remaining thirteen (32.5%)
patients were questioned over the telephone and their
response recorded. The average hospital stay recorded
was 5-6 days. No recurrence was encountered in the
follow up group.

Symptomatology: The main presenting complaint in

all the fifty patients (100%) was swelling of abdomen
in the vicinity of the previous operative scar. This was
followed by dragging pain at the site of hernia in thirty
six percent of patients (n=18) and irreducibility in
fourteen percent of patients ( n=7).
Table-2
Clinical Presentation of Patients with Incisional
Hernia
Sr.No. Clinical
No. of
Percentage
features
Patients
1
Swelling of
50
100.0
abdomen
2
Dragging pain
18
36.0
3
Irreducibility
7
14.00
Incisions: Sixty percent (n=30) patients had midlines
incision causing the incisional hernia. This was
followed by Pfannensteil incision in Fourteen percent
(n=7) and paramedian incision in twelve percent (n=6)
patients.
Postoperative complications:
After sublay
meshplasty, the postoperative complications are shown
in Table 3. Major wound infection was encountered in
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Table-3
Postoperative Complications of Sublay Mesh
Implantation in Incisional Hernia Repair.
Complications
No. of
Percentage
Patients
Major Wound
2
4.00
Infection
Seroma formation
1
2.00
Recurrence of
Nil
0.00
Hernia
Wound sinus
Nil
0.00

DISCUSSION
Incisional hernia is produced by deficient wound
healing from the very beginning or by gradual yielding
of an apparently soundly healed wound. It is estimated
that 2- 11% of all abdominal operations result in an
incisional hernia [3]. Small hernias less than 2.5cm in
diameter are often successfully closed with primary
tissue repairs. However larger ones have a recurrence
rate upto 30-40% when tissue repair alone is
performed alone [15,16,17].
Hernia recurrence is distressing to the patient and
embarrassing to surgeon. Nowadays tension free repair
using prosthetic mesh has decreased the recurrence to
negligible. Despite excellent results, increased risk of
infection with implantation of a foreign body and cost
factor still exist.
However primary tissue repair is associated high
unacceptable recurrence rate but nowadays tension free
mesh repair is ideal hernia repair technique [18, 19].
According to literature, incisional hernia occurred
more frequently in5th and 6th decades of life and
females have higher frequency than males with the

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ratio of 2.4: 1 [20]. In our study, the majority of

patients (80%) were in 30- 60 years age group with
female to male ratio of 4:1. The difference in age
group and higher female preponderance is most
probably due to higher number of lower midline
incisions used in females for obstetric and
gynaecological operations resulting in incisional hernia.
The preperitoneal plane is the ideal logical plane for
the placement of prosthetic mesh [11-14]. Diabetes
[20], postoperative wound infection [21], obesity [22]
are the important risk factors for the development of
incisional hernia in international literature. In our study,
postoperative wound infection after the initial surgery
has the highest incidence (80%) followed by obesity
(40%) and diabetes (14%).
Majority of incisional hernias (80%) developed in the
first two years as per international studies [23]. Our
study indicated that 100% of incisional hernias
developed within first year of initial operation. The
incidence of major wound infection in this study is 4%
which is quite comparable to international studies
[24].The recurrence rate of preperitoneal (Sublay)
mesh repair mentioned in different series varies from
2% to less than 10% [25]. Our study indicated 0%
recurrence with even better results.
CONCLUSION
Although preperitonenal implantation of mesh or
sublay meshplasty is not a new method of repair but
still lots of work needs to be done in future. We had a
follow up of 80% of patients with no recurrence in the
follow up group and less postoperative complications.
Therefore our study affirms that preperitoneal mesh
repair or sublay meshplasty is the ideal repair
technique and highly recommended for large midline
incisional hernias [5].
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AUTHORS
Dr. Fakhar Hameed
Assistant Professor Surgery,
Punjab Medical College, Faisalabad.
Dr. Bashir Ahmed
Senior Registrar Surgical Unit-I,
Allied Hospital, Faisalabad.
Dr. Asrar Ahmed
Senior Registrar Surgical Unit-I,
Allied Hospital, Faisalabad.
Prof. Dr. Riaz Hussain Dab,
Professor of Surgery,
Punjab Medical College, Faisalabad.
Allied Hospital, Faisalabad.
Dr. Dilawaiz
Senior Registrar Surgical Unit-I,
Allied Hospital, Faisalabad.

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